The Influence of Neurocognitive Impairment, Depression, and Alcohol Use Disorders on Health-Related Quality of Life among Incarcerated, HIV-Infected, Opioid Dependent Malaysian Men: A Moderated Mediation Analysis

Depression as a mediator of the association between vision and/or hearing loss and recent substance use: NHANES 2013-2018

BACKGROUND

Previous research has demonstrated a significant association between vision and/or hearing loss and lifetime substance use.

OBJECTIVE

The objective of this analysis was to assess whether depression mediates the association between vision and/or hearing loss and recent substance use (RSU).

METHODS

Data from 9408 NHANES 2013-2018 participants were used for a survey-weighted analysis to assess whether the indirect effect (IE) of disability status (neither, vision loss only, hearing loss only, both) on the outcome RSU (past 30-day use of marijuana, cocaine, methamphetamine, or heroin) was mediated by recent (past 2 weeks) depression (Patient Health Questionnaire- 9 items score; none = 0-4, mild or greater = 5+), adjusting for confounders.

RESULTS

The estimated prevalence of vision and/or hearing loss, mild or greater depression, and RSU were 6.7 %, 24.1 %, and 16.8 %. RSU was significantly positively associated with disability status before (p = .018) but not after adjusting for depression (p = .160), and the indirect effects were statistically significant (p < .001).

CONCLUSIONS

The data are consistent with the hypothesis that recent depression mediates the association between vision and/or hearing loss and RSU. Initiatives may be needed that incorporate a focus on the prevention, management, or care for depression to intervene on the pathway between hearing and/or vision loss and RSU.

The Role of Depressive Symptoms and Physical Activity Levels in Mediating the Association Between HIV Status and Neurocognitive Functions Among Individuals Aged at Least 50 Years in China: Cross-sectional Study

BACKGROUND

Neurocognitive impairments are prevalent among older people in China. It is more problematic among older people living with HIV.

OBJECTIVE

This study aims to compare neurocognitive performance between older people living with HIV and HIV-negative controls, and to explore whether the association between HIV status and neurocognitive performance was mediated by depressive symptoms and level of physical activity.

METHODS

A cross-sectional study was conducted in Yongzhou, China. All people living with HIV aged ≥50 years listed in the registry were invited. Frequency matching was used to sample HIV-negative controls from the general population according to the distribution of age, sex, and years of formal education of older people living with HIV. A total of 315 older people living with HIV and 350 HIV-negative controls completed the face-to-face interview and comprehensive neuropsychological assessment of seven domains (learning, memory, working memory, verbal fluency, processing speed, executive function, and motor skills).

RESULTS

As compared to HIV-negative controls, older people living with HIV performed worse in global score and all seven domains (P<.05). HIV infection was associated with higher depressive symptoms (P<.001) and lower level of physical activity (P<.001). Depressive symptoms and physical activity were negatively correlated (P<.001). Depressive symptoms and level of physical activity mediated the association between HIV status and global z-score and four domain z-scores of neurocognitive performance (learning, memory, verbal fluency, and processing speed).

CONCLUSIONS

Change in mental health and physical activity after HIV infection may partially explain why older people living with HIV are more susceptible to neurocognitive impairment. Promoting mental health and physical activity are potential entry points to slow down the progress of neurocognitive impairment among older people living with HIV.

Aerobic exercise for HIV-associated neurocognitive disorders in individuals on antiretroviral therapy: A randomised controlled trial

INTRODUCTION

The increasing burden of self-limiting forms of HIV-associated neurocognitive disorder (HAND) in the antiretroviral therapy era calls for adjunctive interventions. The study aimed to determine the effects of a 12-week aerobic exercise programme on HAND.

METHODS

This is a parallel-group, randomized controlled trial with concealed allocation and intention-to-treat analysis. This study was a clinic-based programme. Seventy-three patients with HAND were enrolled in the trial. The intervention comprised a moderate-intensity aerobic exercise, 20-60 min per session, three times per week, for twelve weeks. The control group received exercise education. Prevalence of HAND constituted the primary outcome. HAND was identified and classified following the Frascati criteria. We computed the odds ratio and number needed-to-treat to estimate the treatment effect.

RESULTS

There were 73 patients (38 in exercise and 35 in control arm). Individuals in the exercise arm recorded a significantly higher reduction in working memory deficit (OR = 5.14; CI  =  2.6-10.4; NNT  =  6) but not in attention-deficit (OR = 0.31, CI  =  0.2-0.5; NNT = -5) compared to the control group at twelve-week. Reductions in attention deficit (OR = 1.55, 95 CI  =  1.0-2.4; NNT  =  5) and HAND prevalence (OR = 1.8, 95 CI  =  1.2-2.8); NNT  =  8) were significantly higher in the exercise group compared the control group at three-month. No significant between-group difference in functional independence was observed immediately after exercise (p > 0.05).

DISCUSSION

The neuroprotective effects of aerobic exercise appear selective and vary with cognitive abilities impaired and aerobic capacity, with a greater change occurring with improved aerobic capacity.

CONCLUSION

Individuals with working memory and attention deficits may benefit more from moderate-intensity aerobic exercise.

Effects of aerobic exercise on quality of life of people with HIV-associated neurocognitive disorder on antiretroviral therapy: a randomised controlled trial

BACKGROUND

HIV-associated neurocognitive disorder (HAND) negatively impacts quality of life (QoL) of people living with HIV who are on antiretroviral therapy (ART). Behavioural intervention adjunct to ART may improve QoL of people with HAND. We determine the effect of a 12-week aerobic exercise programme on QoL in people with HAND who were receiving ART.

TRIAL DESIGN

This was a parallel-group, randomised controlled trial with concealed allocation and intention-to-treat analysis.

METHODS

We identified 73 participants diagnosed with HAND. Participants were sampled from an earlier study that examined the prevalence of HAND according to the Frascati criteria. Participants were randomised and allocated to an intervention of 12-weeks of aerobic exercise, comprising three 20-60 min sessions per week of moderate-intensity aerobic exercise using a cycle ergometer. The primary outcome was QoL, which was evaluated using the World Health Quality of Life Questionnaire (WHOQoL)-BREF.

RESULTS

Participants in the exercise (n = 39) and control (n = 35) groups had similar sociodemographic characteristics (p > 0.05). Following the 12-week aerobic exercise programme, participants in the exercise group had improved physical (p < 0.001), psychological (p = 0.008) and environmental (p = 0.001) domains of the QoL (p = 0.001) and overall QoL (p = 0.001) relative to the control group. Similarly, participants in the exercise group had lower depression scores than participants in the control group. Depression scores in the exercise group were still lower 3 months post-intervention (p = 0.007). Only the improvements in physical (p = 0.02) and psychological (p = 0.007) domains of QoL were sustained at 3 months post-intervention.

CONCLUSIONS

Aerobic exercise improves the QoL of people with HAND. To ensure sustained benefits, people with HAND may need to engage in long-term physical exercise. Trial registration The trial is registered with the PAN African Trial Registry (PACTR). Date: 01/09/2020, ID: PACTR202009483415745.

Impact of HIV-associated cognitive impairment on functional independence, frailty and quality of life in the modern era: a meta-analysis

HIV-associated neurocognitive disorder (HAND) is an important sequela of HIV infection. Combined antiretroviral therapy (cART) has improved the health outcomes of many people living with HIV but has given rise to a less severe but limiting form of HAND. The study aimed to evaluate the impact of HAND on medication adherence, activities of daily living (ADL), quality of life and frailty. This systematic review adheres to the guidelines for Preferred Reporting Items for Systematic Reviews and Meta-Analyses. We searched MEDLINE, PubMed, CINAHL, Academic Search Complete, and PsycINFO online databases. Studies were included if they examined the relationship between HAND and medication adherence, ADL, quality of life and frailty, and were conducted between 1997 and 2021. We used a random-effects meta-analysis model to assess the impact of HAND on outcome variables. Forty papers, totaling 11,540 participants, were included in the narrative and quantitative syntheses. Cognitive impairment was associated with poorer medication adherence (r = 0.601, CI 0.338 to 0.776, p = 0.001, I² = 94.66). Cognitive impairment did not influence ADL (r = 0.167, CI-0.215 to 0.505, p = 0.393) and quality of life (r = 0.244, CI 0.117 to 0.548, p = 0.182). In the cART era, HAND appears to be associated with adherence to medication, which may influence future health outcomes. In PLWHIV who are adherent to cART, cognitive impairment does not appear to interfere with ADL and quality of life.

Neurocognitive impairment and health-related quality of life among people living with Human Immunodeficiency Virus (HIV)

The association between HIV-associated neurocognitive impairment (NCI) and health-related quality of life (HRQoL) is not well known. We investigated this association among the CNS (Central Nervous System) HIV Antiretroviral Therapy Effects Research (CHARTER) study participants. We performed factor analysis to distinguish physical and mental HRQoL, followed by general linear models. We analyzed 1,340 HIV participants, including 35.6% with NCI, 77.2% males, 70.5% unemployed, and 42.2% with depression. Impaired participants had lower (worse) mental and physical HRQoL mean scores compared to unimpaired participants. NCI was negatively associated with mental HRQoL in crude (mean difference: -4.38; 95% CI: -6.70 to -2.06) and adjusted analysis (-2.56, -4.83 to -0.30). NCI was also negatively associated with physical HRQoL in unadjusted analysis (-4.62, -7.45 to -1.78), though the association weakened in the adjusted analysis (-2.20, -4.81 to 0.40). The association between NCI and HRQoL was confounded mainly by employment and was partially mediated by depression. These findings suggest that future strategies aimed at improving HRQoL among HIV-infected patients with NCI might benefit from concurrent management of depression.

Preference for and Efficacy of a PrEP Decision Aid for Women with Substance Use Disorders

BACKGROUND

Women with substance use disorders (SUDs) are a key population for HIV prevention with pre-exposure prophylaxis (PrEP), though uptake is limited by awareness of PrEP, misestimation of personal HIV risk, and minimally integrated HIV prevention and addiction treatment services. Patient-centered decision aids (DA) could address these barriers to PrEP, but no extant DA for PrEP has been published, including for women with SUDs.

METHODS

We developed a patient-centered PrEP DA for women in addiction treatment. In a pilot randomized preference trial, we compared the DA to enhanced standard of care (eSOC) providing standardized information. The primary outcome was opting to receive more information through the DA; we also assessed the impact of the DA on PrEP decisional preference and PrEP uptake over 12 months.

RESULTS

A total of 164 enrolled participants (DA: 83; eSOC: 81) were similar in terms of HIV risk and demographics, which are representative of women in addiction treatment programs nationally, and most (92%) had opioid use disorder. Half of participants were PrEP eligible, though 37% underestimated their personal HIV risk. Independent correlates of selecting the PrEP DA relative to eSOC included higher alcohol use severity (aOR 4.13, 95% CI 1.05-16.28, p=0.04) and perception of high risk for HIV (aOR 2.95, 95% CI 1.19-7.35, p=0.02). For those selecting the DA, interest in PrEP increased significantly from 25% to 89%. DA participants were also significantly more likely than eSOC participants to see a provider for PrEP during follow-up (15.7% vs 6.2%; p=0.05).

CONCLUSION

Half of the women selected to use the DA, and those who did significantly increased their engagement in the HIV prevention cascade through increased interest in and initiation of PrEP. Future iterations should accelerate the HIV prevention cascade for women with SUDs by integrating PrEP decision aids into existing addiction treatment services and actively linking women to PrEP.

Verification of phycological factors related to health-related quality of life in elderly knee osteoarthritis: A prospective cohort study

BACKGROUND

In recent years, locomotive syndrome, which is a condition requiring nursing care due to musculoskeletal disease, has been reported, and interest in knee osteoarthritis has been increasing. Several studies have reported the physical factors influencing the relationship between knee osteoarthritis and health-related quality of life (HRQOL), but there have been no reports verifying the changes over time in the relationship between psychosocial factors and HRQOL. This study aimed to investigate the influence of psychosocial factors on HRQOL in elderly patients with knee osteoarthritis.

METHODS

Evaluations were conducted at four time points: before exercise therapy intervention, 1 month into intervention, 3 months into intervention, and 1 month after completion of intervention. The items investigated were (1) Japanese Orthopedic Association (JOA) score, (2) Kellgren-Lawrence (K-L) grading system, (3) Fall Efficacy Scale (FES), (4) Frenchay Activities Index (FAI), (5) Geriatric Depression Scale (GDS), and (6) Short Form-8 (SF-8).

RESULTS

No significant differences were seen between each time point of exercise therapy intervention in depression and HRQOL scale but a significant improvement was seen in instrumental ADL and fear of falling at 3 months into intervention. On multiple regression analysis with SF-8 subscales, fear of falling and degree of depression were determined as significant factors affecting physical and mental summary scores.

CONCLUSION

Elderly patients with knee osteoarthritis require not only intervention for knee function, but also psychological intervention to address decreased activity and depression to improve their HRQOL.

The Role of Mental Health Conditions in the Diagnosis of Neurocognitive Impairment in People Living with HIV

The aims of the present study were to evaluate the prevalence of undiagnosed mental health conditions (UMHC) in people living with HIV (PLWHIV) on antiretroviral treatment and with long-term suppressed HIV viremia, and its association with neurocognitive impairment (NCI). A cross-sectional observational study on HIV subjects, ≥18 years old, on stable antiretroviral treatment and with HIV viral load <50 copies/mL was carried out. Patients with known comorbidities, substances abuse, anxiety or depression were excluded. UMHC were evaluated by the Millon Clinical Multiaxial Inventory-III and NCI by Frascati criteria. The association between NCI and sociodemographic, clinical HIV variables and mental health conditions was analyzed. Further, the relationship between mental health conditions scores and NCI diagnosis was evaluated. Eighty patients were included, 37.5% had at least one undiagnosed mental health condition, and 26.3% had NCI. The most frequent mental health conditions were: anxiety (21.3%); bipolar disorder (11.3%); and substance dependence (8.8%). Only longer time since HIV diagnosis (p = 0.030) and at least one mental health condition diagnosis (p = 0.002) showed an association with NCI. Participants with NCI presented higher scores in anxiety, alcohol dependence and post-traumatic stress. Undiagnosed mental health conditions are frequent in PLWHIV. These disorders cannot be identified by HIV clinicians or basic screening questionnaires, and they are not usually self-reported by patients. UMHC could act as confounders in the evaluation of NCI.

Frailty and Neurocognitive Impairment: Impacts on Quality of Life in HIV

Little is known about the effects of aging-related conditions on health-related quality of life (HRQOL) among people living with HIV (PLWH). The purpose of our study was to examine the independent effects of neurocognitive impairment (NCI) and frailty and the interactive effects with HIV serostatus on HRQOL. Our sample consisted of 121 adults (63 PLWH and 58 HIV-uninfected) participating in the Multi-Dimensional Successful Aging among HIV-Infected Adults study at the University of California, San Diego. HRQOL was measured with the Medical Outcome Study 36-Item Short Form Health Survey scale. We found that frailty was significantly associated with HRQOL (p < .001) in the overall sample, and this effect was significantly stronger for PLWH than HIV-uninfected adults. NCI was not significantly associated with HRQOL in our sample. Frailty may be a particularly important factor in HRQOL for PLWH, highlighting the need for prevention and intervention strategies to mitigate the risks for frailty.

Developing an Integrated, Brief Biobehavioral HIV Prevention Intervention for High-Risk Drug Users in Treatment: The Process and Outcome of Formative Research

To date, HIV prevention efforts have largely relied on singular strategies (e.g., behavioral or biomedical approaches alone) with modest HIV risk-reduction outcomes for people who use drugs (PWUD), many of whom experience a wide range of neurocognitive impairments (NCI). We report on the process and outcome of our formative research aimed at developing an integrated biobehavioral approach that incorporates innovative strategies to address the HIV prevention and cognitive needs of high-risk PWUD in drug treatment. Our formative work involved first adapting an evidence-based behavioral intervention-guided by the Assessment-Decision-Administration-Production-Topical experts-Integration-Training-Testing model-and then combining the behavioral intervention with an evidence-based biomedical intervention for implementation among the target population. This process involved eliciting data through structured focus groups (FGs) with key stakeholders-members of the target population (n = 20) and treatment providers (n = 10). Analysis of FG data followed a thematic analysis approach utilizing several qualitative data analysis techniques, including inductive analysis and cross-case analysis. Based on all information, we integrated the adapted community-friendly health recovery program-a brief evidence-based HIV prevention behavioral intervention-with the evidence-based biomedical component [i.e., preexposure prophylaxis (PrEP)], an approach that incorporates innovative strategies to accommodate individuals with NCI. This combination approach-now called the biobehavioral community-friendly health recovery program-is designed to address HIV-related risk behaviors and PrEP uptake and adherence as experienced by many PWUD in treatment. This study provides a complete example of the process of selecting, adapting, and integrating the evidence-based interventions-taking into account both empirical evidence and input from target population members and target organization stakeholders. The resultant brief evidence-based biobehavioral approach could significantly advance primary prevention science by cost-effectively optimizing PrEP adherence and HIV risk reduction within common drug treatment settings.

Intent to Use Preexposure Prophylaxis (PrEP), HIV Risk Behaviors, and Self-Report Neurocognitive Symptoms by High-Risk Drug Users: A Mediation Analysis

Neurocognitive impairment (NCI) and HIV risk are significant correlates of intent to use preexposure prophylaxis (PrEP). The extent to which similar outcomes could occur when these factors operate together, particularly for people who use drugs (PWUD), remains an important unanswered question. We therefore sought evidence that HIV risk behavior mediated the relationship between NCI and intent to use PrEP in high-risk PWUD in treatment. HIV-uninfected, methadone-maintained people who reported HIV-risk behaviors were enrolled (n = 400). Variables of interest (NCI, HIV risk behaviors, intent to use PrEP) were assessed using audio computer-assisted self-interview. We found preliminary evidence of indirect effect of HIV risk behaviors, such that NCI had an increased impact on intent to use PrEP via HIV risk behaviors. As a result of having this information, clinicians and researchers will be better equipped for evidence-informed targeting and dissemination efforts to optimize PrEP uptake by this underserved population.

A Self-Report Measure to Detect Neurocognitive Impairment among Incarcerated People Living with HIV in Malaysian Context: An Exploratory Factor Analysis

While neurocognitive impairment (NCI) among people living with HIV (PLWH) who use drugs and its impact on HIV treatment outcomes continue to be widely investigated, there remains a critical gap in NCI assessment among HIV-infected people who use drugs (PWUD) in Malaysian context. The present study, therefore, sought to improve the utility of the existing Neuropsychological Impairment Scale (NIS) as a screening tool for assessing NCI by establishing its psychometric properties in the Malaysian context. The NIS is a brief, self-report measure originally designed to assess NCI by having individuals rate a range of items that may influence cognitive functioning. HIV-infected male prisoners (N=301) administered the full 95-item NIS. An exploratory factor analysis (EFA) was conducted using principal axis factoring and orthogonal varimax rotation. Reliability was measured using Cronbach's alpha. The EFA resulted in an abbreviated, psychometrically sound, eight-factor structure (54-item) revised NIS - now referred to as the Brief Inventory of Neuro-cognitive Impairment-Malaysia (BINI-M). It is better designed to detect NCI in PLWH, ranging from generalized neurocognitive symptoms to more specific forms of impairment with excellent to average reliability. The BINI-M may serve as a useful tool for clinicians and researchers to assess NCI in PLWH and can inform enhanced treatment strategies in the Malaysian context.

A Moderated Mediation Model of HIV-Related Stigma, Depression, and Social Support on Health-Related Quality of Life among Incarcerated Malaysian Men with HIV and Opioid Dependence

Although it is well established that HIV-related stigma, depression, and lack of social support are negatively associated with health-related quality of life (HRQoL) among people living with HIV (PLH), no studies to date have examined how these psychosocial factors interact with each other and affect HRQoL among incarcerated PLH. We, therefore, incorporated a moderated mediation model (MMM) to explore whether depression mediates the effect of HIV-related stigma on HRQoL as a function of the underlying level of social support. Incarcerated HIV-infected men with opioid dependence (N = 301) were recruited from the HIV units in Kajang prison in Malaysia. Participants completed surveys assessing demographic characteristics, HIV-related stigma, depression, social support, and HRQoL. Results showed that the effect of HIV-related stigma on HRQoL was mediated via depression (a1:β = 0.1463, p < 0.001; b1:β = -0.8392, p < 0.001), as demonstrated by the two-tailed significance test (Sobel z = -3.8762, p < 0.001). Furthermore, the association between social support and HRQoL was positive (β = 0.4352, p = 0.0433), whereas the interaction between HIV-related stigma and depression was negatively associated with HRQOL (β = -0.0317, p = 0.0133). This indicated that the predicted influence of HIV-related stigma on HRQoL via depression had negative effect on HRQoL for individuals with low social support. The results suggest that social support can buffer the negative impact of depression on HRQoL and highlights the need for future interventions to target these psychosocial factors in order to improve HRQoL among incarcerated PLH.

Treatment Engagement Moderates the Effect of Neurocognitive Impairment on Antiretroviral Therapy Adherence in HIV-Infected Drug Users in Treatment

Neurocognitive impairment (NCI) and treatment engagement (TE) have been shown to significantly predict antiretroviral therapy (ART) adherence, but no studies have explored the ways and the extent to which similar outcomes might occur when these factors operate together, particularly for people who use drugs (PWUDs). We sought to discover whether TE moderated the effect of NCI on adherence to ART in HIV-infected individuals. One hundred sixteen HIV-infected, methadone-maintained people who reported HIV risk behaviors were enrolled in the study. Variables of interest (NCI, ART adherence, TE) were assessed using audio computer-assisted self-interview. Results revealed a significant interactive effect of NCI and TE on ART adherence, which supported the moderation effect. Findings from post hoc analyses showed that NCI was negatively associated with adherence to ART at low levels of TE. Findings suggest the need to accommodate individual NCI and improve TE as a means to enhance ART adherence in HIV-infected PWUDs.